Transcript Document

Delivery System Design
Mike Hindmarsh
Improving Chronic Illness Care
California Chronic Care Learning Communities
Initiative Collaborative
Learning Session 1
ICIC Website:
http://www.improvingchroniccare.org
Chronic Care Model
Community
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Health System
Health Care Organization
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Delivery System Design
• Define roles and distribute tasks amongst team
members.
• Use planned interactions to support evidencebased care.
• Provide clinical case management services.
• Ensure regular follow-up.
• Give care that patients understand and that fits
their culture
To improve outcomes in chronic
illness
• Patients must be prescribed and taking
proven therapies
• Patients must be managing their illness
well
• Patient course must be followed for
changes in status and reinforcement
The problem
• Patients are frustrated by waits and
discontinuities, often don’t receive proven
services and often feel they are not
heard.
• Providers feel they have little control over
their work life, are stressed by demands
for productivity despite older, sicker
clientele and the reduced variability in
their clinical day.
What we know about primary
care visits?
• 50-70% are largely informational or
informative (including check-backs for
chronic illness care) yet they are
organized like acute visits
• US average is 16.3 minutes
• Patients are given an average of 20
seconds to tell their story before they are
interrupted
What we know about primary
care visits? (cont.)
• When uninterrupted, 50% of patients
finished their story in 60 seconds or less,
80% in 2 minutes or less.
• For the same set of patient
characteristics, physicians varied the
interval between visits from 4-20 weeks.
• Non-physician staff are generally more
likely to adhere to protocols
What we know about primary
care visits? (cont.)
• For pediatric patients with asthma,
continuity of care is associated with 5060% reductions in ER use and
hospitalizations
• The physician part of the visit is shorter
when non-physician staff are used to their
capacity.
Old interaction vs. new interaction
Between doctor/NP/PA
and patient
Face-to-face
Between patient and
care team
Multiple methods
Problem-initiated and
focused
Topics are clinician’s
concerns and treatment
Ends with a prescription
Based on care plan:
“planned visit”
Collaborative problem
list, goals and plan
Ends with a shared plan
of care
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
•Assessment of self-management skills and
confidence as well as clinical status
•Tailoring of clinical management by stepped
protocol
•Collaborative goal-setting and problem-solving
resulting in a shared care plan
•Active, sustained follow-up
Define roles and tasks
Distribute them among the team members.
Care is a team sport
• Team development
• Review process for care
• Assign tasks, matching licensure and
skills.
• Cross train staff
• Use protocols and standing orders
Example of task distribution
Microalbuminuria testing
• Receptionist recognizes patient has diabetes,
attaches req. to chart
• MA collects specimen
• RN reviews slip, recognizes out-of-range tests,
orders confirmatory test, discusses possible
need for ACE inhibitor
• MD discusses and prescribes ACE inhibitor
• RN calls pt. to check on med. adherence and
side effects
Roles in Team Care
ROLE
PRIMARY
CARE
PROVIDER
PRIMARY
CARE
NURSING
STAFF
MEDICAL
SPECIALIST
CLINICAL
CARE
MANAGER
RESOURCE
COORDINATOR
CLERICAL
STAFF
Use planned interactions to
support evidence-based care
One-on-one, group, telephone, email,
outreach….the possibilities are endless
What is a Planned Visit?
• A Planned Visit is an encounter with the patient
initiated by the practice to focus on aspects of
care that typically are not delivered during an
acute care visit.
• The provider’s objective is to deliver evidencebased clinical management and patient selfmanagement support at regularly scheduled
intervals without the “noise” inherent in the
acute care visit.
What does a Planned Visit look like?
• The provider team proactively calls in patients
for a longer visit (20-40 minutes) to
systematically review care priorities.
• Visits occur at regular intervals as determined
by provider and patient.
• Team members have clear roles and tasks.
• Delivery of clinical management and patient
self-management support are the key aspects
of care.
How do you do a Planned Visit?
You Plan It!
Step One: Example Type II Patients with
Diabetes
• Choose a patient sub-population, e.g., all
patients A1c >9.5 from registry
• Identify patients who have not been seen
recently as priorities
• Review chart for needed medical
management
Step Two: Patient Outreach
• Have front office call patient and explain the need
for planned visit
• Allow patient to choose day and time for visit
• Ask patient to come to lab for A1c one week prior
to visit
• Ask patient to bring in all medications and any
blood sugar data
Step Three: Preparing for the Visit
• RN/LPN/MA prints patient summary from
registries and attaches to front of chart
• MD reviews medications and labs prior to
visit, and consults with pharmacy as
needed
Step Four: The Visit
• Review patient’s medication regimen
• Examines feet
• Referrals for eye care and other specialties as
needed
• Discuss importance of good self-management
• Create an patient action plan
• Schedule follow-up
Step Five: Follow-up
• Does not need to be in-person visit (use
phone, email)
• Check adherence to action plan
• Problem solve as needed
• Schedule additional follow-up as needed
Group Visits: Introduction
• Patients brought in by clinically relevant
groups
• Patients can receive:
Specialty service as needed/available
One-on-one with medical provider
Medication counseling
Self-management support training
Social support
• Multiple Models for Group Visits
Provide clinical case
management services for
complex patients.
Knowing who needs more support and
finding a way to deliver it.
What is case management?
Many different things to different people
• Resource coordination
• Utilization management
• Follow-up
• Patient education
• Clinical management
Case mgmt: Positive clinical
trials
• clinically skilled case manager using
protocols
• close linkages to primary care and
specialty expertise
• close follow-up and strong selfmanagement support
Diabetes Nurse Case Management
Health System:
Community
Prudential Jacksonville
SelfManagement
Support:
1:1 visits with
trained RN,
follow-up
support,
pt. Ed class
Informed,
Activated
Patient
Decision
Support:
Delivery
Detailed
System
manageDesign:
ment
case mgmt.
algorithms
RN in clinic,
,
routine meetings
specialist
with PCP
consult.
Productive
Interactions
Clinical
Information
Systems
diabetes registry,
patient
monitoring logs
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Aubert et al Ann Int
Med 1998;129:605
decreased HbA1c
no increase in adverse events
improved self-reported health status
Case mgmt: Negative clinical
trials
• nurse or social worker without specific
clinical experience or training
• no clear goals or protocols
• limited connection to primary care
Non-specific Nurse Case Management
Health System
Community
Resources and Policies
Health Care Organization
Regional health system
developed a guide
referred patients
SelfManagement
Support
trained to
emphasize patient
strengths
Patient/
Caregiver
Gagnon et al, JAGS
1999; 47:1118-1124
Delivery
System
Design
intensive
case mgmt
(home visit
every 6 wks,
monthly
phone calls)
Decision
Support
no clinical
guidelines
consult with
geriatrician
and team
Problem-Centered
Interactions
Clinical
Information
Systems
used a nursing
documentation
program
Case manager
linked to others
Increased hospitalization
No change in functional status
Key changes for case
management
• Develop patient selection criteria
• Determine availability of services
• If available, work together
• If not, review team roles and tasks and fill
in gaps.
• Assure that patients receive CM services.
Features of effective case
management
• Regularly assess disease control,
adherence, and self-management status
• Either adjust treatment or communicate
need to physician immediately
• Provide self-management support
• Provide more intense follow-up
• Assist with navigation through the health
care process
What do you do if you can’t hire
a clinical case manager?
• Evidence suggests that non-professionals
can be trained to perform follow-up and
assessment.
• That alone when linked to a physician or
nurse case manager has improved
outcomes in depression and arthritis
• Automatic Voice Response telephone
systems can perform this function.
Ensure regular follow-up by
the primary care team
The alternative to lost to follow-up…
Making follow-up work for you
• Develop process for follow-up
• Tailor follow-up to patient and provider
needs
• Eliminate unnecessary follow-ups
• Schedule follow-up.
• Monitor for missed follow-up.
• Reach out to those not attending followups.
Follow-up could be…
• Face-to-face
• Clinical case manager
• Outreach worker
• In groups
• Phone
• E-mail
Contact us:
•www.improvingchroniccare.org